1. What do changes in cardiopulmonary resuscitation (CPR) techniques as recommended by the American Heart Association (AHA) include?
a. Compress the chest 100 times a minute.
b. Depress the chest at least1 inch.
c. Before compressions, administer three strong breaths.
d. Elevate the patients hips.
ANS: A
The current AHA recommendations state that after the patient is assessed, the rescuer should begin chest compressions at 100 compressions a minute and depress the chest to 2 inches. Mouth-to-mouth breathing is no longer recommended. New research suggests that abdominal compressions are less injurious to the patient and more effective in terms of providing blood circulation.

2. Standing in a fast-food line, the person in front, while munching on a cookie, begins to cough heavily, takes deep inspirations, and waves his arms around wildly. What should be the nurses first action?
a. Start rescue breathing as quickly as possible.
b. Start chest compressions as quickly as possible.
c. Perform abdominal thrusts.
d. Do nothing at this point as long as air is exchanged.
ANS: D
When a person is choking but alert enough to attempt to cough and force the obstruction up and out by himself, allowing him to do so alone is best because more expelling force occurs that way. Only when the person shows signs of not being able to breathe beyond the obstruction should abdominal thrusts be applied.

3. What is the initial intervention for an unconscious patient who is not breathing according to one-person CPR principles, as taught and practiced by professional nurses?
a. Lift the jaw to clear the airway.
b. Call for assistance.
c. Start chest compressions.
d. Remove patient clothing to visualize the chest.
ANS: B
With one-person CPR, when the patient is unconscious and not breathing, the first thing to do is to call for help.

5. A nurse comes upon a traffic accident. One passenger is lying on the ground by an open door. What should the nurse assess for first?
a. Uncontrolled bleeding
b. Circulation, airway, and breathing (CAB)
c. Abdominal deep wounds
d. Level of consciousness (LOC) and orientation
ANS: B
The CAB method of emergency assessment reminds the caregiver to check the essentials first.

6. A nurse follows the protocol of SAMPLE when speaking to a victim of a fall in the parking lot of the hospital. What does the P stand for?
a. Pills taken today
b. Personal physician
c. Past illnesses
d. Preference for emergency transportation
ANS: C
The acronym SAMPLE that guides the victim interview means allergies, medications, past illness or pregnancy, last food and drink, and events related to injury.

7. What instructions should the nurse provide for immediate treatment for epistaxis?
a. Stand still, lean your head back so that the blood wont get all over everything, and pinch your nose shut for at least 10 minutes.
b. Stand still, lean your head forward, and pinch your nose tightly for at least 10 minutes.
c. Sit down on a solid surface, lean your head forward to let the blood run out, and then pinch your nose closed for at least 30 minutes.
d. Sit down on a solid surface, lean your head forward so you dont choke on the blood, and pinch your nose shut for at least 10 minutes.
ANS: D
Blood from a nosebleed in the anterior portion of the nasal cavity will usually stop with pinch pressure within 10 minutes. Blood from a nosebleed should not be swallowed.

8. Which condition may complicate the assessment of an older adult patient with a suspected head injury?
a. Sensory deficits
b. Slowed metabolism
c. Preexisting cerebral dysfunction
d. Decreased pulmonary function
ANS: A
Sensory deficits, circulatory disorders, and communication problems make it more difficult to assess an older adult patient with a suspected head injury.

9. A nurse is called on to assist a neighbor who needs first aid. What should the nurse know is the legal responsibility for this action?
a. Is legally bound to help in any way possible
b. Is expected to demonstrate the same skill, knowledge, and care that would be provided by other nurses in the same community with the same credentials
c. Has no legal responsibilities outside the hospital setting and would be held accountable for nothing
d. Can legally perform any aid skill, even those not allowed the nurse in the hospital
ANS: B
U.S. laws protect nurses when they act in the same manner as others licensed at their level would do in the same circumstances.

10. A nurse comes upon a traffic accident where injured, unconscious people are lying on the highway. What should the nurse be aware of regarding the sanctioning of first-aid interventions in this scenario?
a. Good Samaritan Act
b. Emergency Care Doctrine
c. Fifth Amendment
d. Liability Protection against Malpractice Act
ANS: A
Most states have Good Samaritan Acts, which protect voluntary caregivers from malpractice claims.

11. What will the nurse giving discharge instructions to a patient who is severely allergic to insect stings caution the patient to do?
a. Wear bright colors to repel insects.
b. Apply perfume liberally as a protection.
c. Dress in sleeveless, easily removable garments.
d. Obtain an emergency treatment kit.
ANS: D
An emergency kit with Benadryl or injectable epinephrine or both are recommended. Insects are attracted by bright colors and perfume. Arms and legs should be covered with clothing.

12. A patient is admitted to the emergency department after having been bitten on the hand by a black widow spider. Which nursing intervention should the nurse initiate?
a. Monitor for respiratory distress.
b. Wrap the hand in a warm compress.
c. Seat the patient upright in a chair.
d. Elevate the patients hand above his or her heart.
ANS: A
Neurotoxins frequently cause anaphylaxis with severe respiratory distress and seizure. Therefore, the patient should be protected from falls, and the hand kept cool and below the heart to delay the spread of the toxin.

13. A nurse who is assisting victims of an automobile collision has already placed a towel secured with a belt on a bleeding leg wound. What action should the nurse take when the towel becomes saturated?
a. Do nothing.
b. Remove the towel and use the belt as a tourniquet.
c. Remove the towel and place the victims jacket over the wound and secure it.
d. Reinforce the towel with the victims jacket.
ANS: D
Direct and continuous pressure is the intervention for a bleeding wound. The original dressing should not be removed but should be reinforced.

14. An accident victim comes to the emergency department with an open chest wound. What should the nurse apply to the wound?
a. Occlusive dressing taped on four sides
b. Tight Ace wrap
c. No dressing of any sort
d. Vented dressing, taped on three sides
ANS: D
A vented dressing taped on three sides allows no more air to enter the pleural space but allows the expanding lung to push air out. A four-sided dressing allows the trapped air to remain and possibly collapse the lung.

15. A homeless person is brought to the emergency department after having been found asleep on a park bench under a layer of snow. He has a rectal temperature of 95 F. Which additional symptoms should the nurse anticipate?
a. Diminished breath sounds and inadequate chest expansion
b. Shivering, decreased heart rate, and increased blood pressure (BP)
c. Confusion, increased hunger, and hypertension
d. Decreased irregular heart and respiratory rates and decreased BP
ANS: D
A patient with hypothermia will continue to chill as his or her vital signs deteriorate.

16. A mother brings in her 2-year-old who has ingested gasoline 1 hour earlier. What should the nurse implement following the initial assessment?
a. Prepare to administer syrup of ipecac.
b. Turn the patient on his or her stomach to induce vomiting.
c. Prepare to administer Milk of Magnesia.
d. Prepare to administer bowel lavage and cathartics.
ANS: D
Bowel lavage and cathartics will rid the body of the petroleum product. Inducing vomiting when the patient has consumed petroleum products is contraindicated. Ipecac is no longer recommended, and Milk of Magnesia will not be effective.

17. While at the local pool on an extremely hot day, a nurse is called on to care for a woman who has evidently developed heat exhaustion. What is the initial nursing care for this person?
a. Obtain vital signs.
b. Move the patient into an air-conditioned or shaded area.
c. Give her several glasses of ice water.
d. Cover her with a wet towel.
ANS: B
The goal for treatment of heat exhaustion is to cool the body initially and slowly in an air-conditioned or shaded area. After the patient is moved, applying wet towels and giving cool drinks are appropriate.

18. A patient comes to the emergency department with an evisceration after a knife attack. What is the best nursing intervention related to the exposed bowel?
a. Gently replace the bowel into the abdominal cavity.
b. Place a sterile wrapped sandbag on the abdomen to prevent further evisceration.
c. Place the patient in a high Fowler position to allow the bowel to drop back into the abdominal cavity.
d. Cover the bowel with a moist saline dressing.
ANS: D
The nurse protects the tissue from further injury and drying out by the application of a sterile saline dressing.

19. A patient visits the industrial nurse after an accident on the factory floor, which has amputated three toes. What is the most effective nursing intervention for the amputated toes?
a. Rinsing with normal saline and placing on a sterile towel
b. Placing toes as they are on ice in a sterile container
c. Placing the unwrapped toes in a saline bath
d. Placing the saline-wrapped toes in a plastic bag in a saline bath
ANS: D
The toes should be wrapped in a saline dressing and placed in an airtight bag in a cool saline bath. The toes should not be in direct contact with ice or be placed in the freezer.

20. Six hours after a beach picnic on a hot afternoon, a young man enters the emergency department with nausea and vomiting, headache, and diarrhea. On interview, the patient says that he ate potato salad and tuna fish sandwiches. What should the nurse suspect is the causative organism for these symptoms?
a. Clostridium botulinum
b. Clostridium perfringens
c. Salmonella
d. Staphylococcus aureus
ANS: D
Staphylococcus aureus incubates in undercooked foods, especially eggs and mayonnaise, and can cause gastrointestinal symptoms in as little as 6 hours after ingesting the food.

21. A child is brought to the emergency department with several deep dog bites on her legs. After cleaning the wounds, what should the nurse be primarily concerned with ascertaining?
a. The whereabouts of the dog
b. The status of tetanus inoculation
c. The rabies status of the animal
d. The childs allergy to the rabies vaccine
ANS: B
Tetanus prophylaxis should be confirmed so that it can be brought up to date, if necessary. The whereabouts of the dog will be the responsibility of the proper authorities, who will also observe it for rabies. Inoculation for rabies is not an immediate concern unless the bites were on the head or face and can be delayed until the dog is found to be rabid or not.

22. A patient is brought to the emergency department having had a rock chip embedded in the right eye. What should be the nurses initial action?
a. Turn the patient to the left side and prepare to remove the chip.
b. Flush the right eye with normal saline.
c. Keep the patient flat.
d. Cover both eyes.
ANS: D
Stabilizing the rock chip is essential to prevent further damage; it should not be removed. Flushing the eye is done for chemical burns. Patient should not be kept flat. Covering both eyes is recommended to prevent eye movement, which could cause further damage.

23. A hospital visitor cuts herself on the arm and is bleeding profusely. What should be the immediate treatment by the nurse?
a. Call any physician and immediately send the visitor to the emergency department.
b. Apply direct pressure to the arm with sterile dressing.
c. Take the visitors blood pressure and pulse.
d. Immobilize the injured arm and send the visitor immediately to the emergency department.
ANS: B
The first actions should be to stop the blood flow, protect the wound from infection, and call for more help or assist the visitor to the emergency department.

24. A young man is staggering out of a partially closed doorway to a garage, where a car is running inside. He speaks slowly in a very low voice, telling the nurse that he fell asleep in the car with the engine running. What is the immediate nursing diagnosis and action?
a. Impaired gas exchange. Ask the person to lie flat right where he is; begin rescue breathing. If the nurse sees anyone else, the nurse should ask the individual to call someone who knows CPR.
b. Impaired gas exchange resulting from the inhalation of carbon monoxide. Lead the patient away from the garage and call for help. Stay with the patient and continually assess level of consciousness and respirations.
c. Impaired circulatory perfusion resulting from sulfur dioxide poisoning. Have the patient lie flat. Keep the patient still and call for help.
d. Impaired gas exchange. Have the patient breathe deeply and continually into a brown paper bag. Assess pulse, respirations, and color of conjunctiva. Check the patients pockets for a cell phone to call 9-1-1.
ANS: B
The man is still conscious enough to speak, but slowly, and therefore does not yet need CPR. Fumes from the garage are entering the air around them. Therefore, getting the nurse and the man away from the fumes is necessary. The man may, at any time, lose consciousness. Sitting down would prevent a fall; consequently, the nurse should call for help. Staying with the young man reassures him and lessens his anxiety response.

25. What should the emergency department nurse anticipate on the initial assessment of a patient with carbon monoxide poisoning?
a. Blood pressure will be low.
b. Oxygen saturation will be low.
c. Mucous membranes will be blue.
d. Respirations will be less than 10 breaths/min.
ANS: B
Carbon monoxide binds to the hemoglobin more readily than oxygen, which causes hypoxemia. The mucous membranes will be cherry red, and the blood pressure will be elevated because of hypoxia.

27. A nurse has assessed the patient with a left-sided head injury and records this information: decreasing level of consciousness; slow pupillary response on the right side; blood pressure, 167/80 mm Hg; previous blood pressure, 160/72 mm Hg; and gradually increasing respiratory and pulse rates. The nurse is aware that these assessments are indicators of _____.

30. How should a nurse intervene for a patient with a perforation of the right eye? (Place the interventions in the appropriate sequence.) (Separate the letters with a comma and space: A, B, C, D.)
A. Cover the right eye with an eye shield.
B. Place the patient in a Fowler position.
C. Clean around the right eye.
D. Cover the left eye with a light occlusive dressing.
E. Darken the room.

ANS:
B, C, A, D, E
The Fowler position will decrease the risk of loss of more fluid from the eye. The area around the eye should be cleaned and the eye covered with an eye shield. The left eye should be covered to prevent sympathetic movement in the right eye. The room should be darkened to reduce pupillary response to light.